A non-partisan and less divisive dialogue should be the goal of Congress and the Administration in trying to solve the healthcare needs of this country. Changes should be made in an incremental fashion and legislation should not be rammed through without a full discussion of the issues involved in the process. Along this vein, a more focused goal seem to be a better alternative to what is currently being debated and the following recommendation is being made based on my observations in surgical practice of close to 40 years in this country. Instead of a Healthcare reform, I wish to change the title to Healthcare Assistance Act.

HEALTHCARE ASSISTANCE ACT

Delivery of comprehensive health care to all segments of society should be the goal in any future legislation. Instead of an overhaul reform, legislation should build on existing, workable solutions to healthcare delivery. Inasmuch as 80% of the population are satisfied with their healthcare insurance coverage, the focus should be twofold: 1) Provide comprehensive health care to the 40 million uninsured members of our society without having to establish another bureaucracy, such as a government funded insurance program which is doomed to annual losses due to waste and fraud ; 2) Devise means by which the two existing government programs, re: Medicare and Medicaid are assured of continued funding, a major component of which is to get rid of waste and fraud, to maintain sustainability and assimilate in an incremental fashion the uninsured segment of our society.

SOLUTIONS: (Broad Outline)

1. Incremental enrollment of uninsured US Citizens and legal immigrants to the Medicare program starting with the working poor especially those with families, followed by those who can barely afford their insurance premiums or unable to fully fund their insurance premiums or unable to afford catastrophic health care needs. Mandatory health insurance should be required of everyone and coverage provided accordingly.
2. The approximately 10 million illegal immigrants should be enrolled in the Medicaid program to be fully funded through the federal government without requiring States to provide funding for any portion of the expenses. Immigration is a function of the Federal government and illegal immigration is the responsibility of the Federal government.
3. Coverage of the uninsured should be a partnership between the individual taxpayer, private sector and the government with cost containment and cost adjustment by various health care related providers: Insurance companies, Pharmaceutical companies, Hospitals and Medical providers.
4. Healthcare Insurance should provide coverage for all catastrophic conditions, long term care, experimental drugs and all pre-existing conditions.
5. Strict enforcement of currently existing Medicare and Medicaid rules and make amendments as required based on recommendations from a non government panel consisting of consumers and providers. Aggressively prosecute criminal activity related to these programs.
6. Improve reimbursement for medical care in both the Medicare and Medicaid program with strict guidelines to prevent waste and fraud.
7. Additional rules and regulations will be developed by the Secretary of Health and presented to Congress for their review and approval focusing on practice guidelines, quality of care issues and preventive medicine programs.

FUNDING: (Broad Outline)

1. GOVERNMENT: Eliminate waste and fraud in the current Medicare and Medicaid programs which is estimated to be approximately $60 billion per year. If necessary, a special investigative arm of the Attorney General’s office should be established to prosecute criminal activity in these programs.
2. TAXPAYERS: Special healthcare tax based on income with incremental increase in accordance with current taxation laws. Tax credit should be allowed for out of pocket expenses related to healthcare, including dental and hearing problems not covered by basic health insurance. Exemptions from this special tax should include the individual taxpayer with an annual income of less than $30,000.00; married couples earning less than $50,000; married couples with children earning less than $75,000.00 annually.
3. SMALL BUSINESS: Those with less than 10 employees should be exempted from a share in funding health insurance to their employees. Instead, these employees should be enrolled into the Medicare program.
4. COST CONTAINMENT: By all providers to broadly include the following:
   • HEALTH CARE FACILITIES: Hospitals (escalating charges which include a hidden tax); limit tertiary care availability and advanced (including experimental) treatments to broad based medical centers with quality programs (proven centers of excellence) that are readily accessible to the citizenry. Not all Hospitals should be allowed to develop specialized programs in cancer, heart disease (cardiac surgery programs), trauma, advanced state of minimally invasive surgery requiring a large financial outlay, etc., without prior authorization and approval by the Secretary of Health. Strict rules should be developed as guidelines.
   • PHYSICIANS: Reimbursement for procedures and excessive charges should be reviewed by a panel consisting of membership from the public, health provider and insurance industry. Appropriate rules and regulations should be enacted to prevent abuse of the system. Emerging and new procedures requiring expensive technology shold be approved by a non government panel consisting of consumers and health care providers. Practice guidelines should be developed and enforced to reduce use of expensive or duplicative sophisticated diagnostic procedures that may not be necessary to make a clinical diagnosis (re: MRI in conjunction with a CT Scan and Ultrasound when the latter maybe all that is necessary); most of which are being ordered for fear of being litigated for malpractice. Develop programs of preventive medicine: re: Obesity, Carcinogens, Healthy life style programs, etc.
   • MEDICAL SCHOOLS AND RESIDENCY PROGRAMS: Should be provided with appropriate funding to develop more programs geared to Family Medicine to encourage every member of society to have their own family physician, thereby preventing the excessive use of Emergency rooms except for legitimate reasons. There is a need for more primary care physicians. In this regard, reimbursement to primary care physicians should be improved and appropriate incentives, re: student loan reimbursement for those medical graduates entering primary care residency programs.
   • TORT REFORM: Excessive non- economic damages given to plaintiffs is definitely a factor in the escalating cost of health insurance and medical malpractice insurance. This has to be a major component of any reform.
   • PHARMACEUTICAL COMPANIES: Charges for new drugs should properly document the percentage of profit being used for research and development and excessive charges primarily for profit should be minimized. Funding for R & D should not be curtailed in order to maintain US pre-eminence in development of new drug treatments. Drug advertising should be limited to the Medical profession and other healthcare providers. Cost savings from general advertising should instead be used for research and development. Reduce the length of patent rights for new drugs so that generic drugs which are considerably cheaper can be purchased as an alternative; otherwise, purchase of drugs should be allowed from international sources.
   • INSURANCE INDUSTRY: Oversight by a non partisan, non government agency with legal rights to develop rules and regulations regarding health insurance rates and coverage with the consent and approval of Congress. Health insurance must cover all basic and complex health care needs with no discrimination to pre-existing conditions. If catastrophic insurance or additional insurance/out of pocket medical expense is required for additional coverage, then premiums for such additional insurance should be given TAX CREDIT. Allow interstate competition in the health insurance market. Encourage development of Health Cooperatives. Make Health Insurance premiums affordable.

MAJOR ADVANTAGES TO THIS RECOMMENDATION:

1. A large number of the US population will benefit from a re-structuring and fine tuning the two major government programs which currently benefit the poor, disabled and elderly members of our society in addition to delivery of healthcare to the uninsured. A major component of making Medicare and Medicaid sustainable is to implement aggressive measures in preventing waste and fraud.
2. Allow sustained funding of these two programs without further increasing the federal deficit which has now ballooned due to the bailouts, current funding for the wars in Iraq and Afghanistan as well as foreign aid.
3. This program will not interfere with currently existing health insurance plans for the majority of the US citizenry who have indicated through various polls (approximately 80%) that they are satisfied with their health care and health coverage.
4. The program will provide health coverage for illegal immigrants who currently become a burden to State governments and to all healthcare providers if and when they require health care; most of which are obtained through the emergency room of hospitals; a very expensive, wasteful and unwise use of an important healthcare resource; which all US citizens with private insurance help support through a hidden tax.
5. Laws must be included for a better oversight of the Medicare and Medicaid programs, all healthcare providers, drug companies and insurance companies.

Eventually, the Congress and this administration will have to address the problem of illegal immigrants. While we have low tolerance for illegal immigrants, the fact of the matter is that:

1. There is no way of having all illegal immigrants return to their home countries. They are here to stay. Furthermore, most illegal immigrants now perform useful services in our society by taking on work that most of our citizen’s refrain from doing.
2. The sooner they are incorporated into our society (with strict rules before they become citizens), the sooner will they become legal participants to all privileges currently enjoyed by citizens and legal immigrants, including paying taxes. Further, their children born in this country are US citizens entitled to the rights and privileges of every citizen in this country. Finally, we should make sure that our borders are secured and that more programs from our government and the private sector are developed to assist our immediate neighbors improve their economy to uplift the living conditions of their citizens thereby drastically reducing the magnitude of illegal immigration.

Hernan M. Reyes, MD, FACS, Boothbay Harbor, Maine, Emeritus Professor of Surgery, Rush University Medical Center, Emeritus Chairman, Department of Surgery, Cook County Hospital, Chicago, Illinois. Email address: Hmrey33@aol.com, Final revised version: August 20, 2009